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Masculinizing Scrotoplasty

Masculinizing scrotoplasty in transmasculine patients uses the labia majora — embryologic homologs of the scrotum — to construct a neoscrotum, with the Hoebeke pedicled-labia-majora U-flap with 90° medial rotation as the modern canonical technique.[1] This page covers the canonical Hoebeke approach alongside its historical predecessors (Hage 1993 bifid V-Y, Sengezer 1993 tissue expansion) and contemporary alternatives (Miller / Chen 2021 bilateral rotational advancement), with technique-specific outcomes, a comparison matrix, and the horseshoe pubic flap component-detail.

The Hoebeke technique was developed by the Ghent gender team (Selvaggi, Hoebeke, Ceulemans, Monstrey) based on 300+ scrotal reconstructions since 1993.[1] It combines a V-Y advancement with a 90° medial rotation of superiorly based labia-majora flaps, addressing the two fundamental problems of earlier techniques: insufficient tissue volume and excessively posterior scrotal positioning.[1] In the largest contemporary outcomes data, the Hoebeke technique is associated with 11.5% testicular-implant explantation vs 20.8% across the historical mix of techniques at the same centre (Pigot 2019, n = 206).[2]

This is the dedicated atlas page covering the canonical Hoebeke technique and its named-variant alternatives. For the cohort-level framework, see Masculinizing Gender-Affirming Surgery. For the downstream prosthetic component, see Testicular Implants (Gender-Affirming). For the cross-indication scrotal-reconstruction ladder, see Scrotal Reconstruction Techniques.

Historical Context and Rationale​

The core challenge of scrotoplasty in transmasculine patients is that the labia majora — embryologic homologs of the scrotum — are positioned too posteriorly (between the legs) and often provide insufficient tissue bulk to simulate a natural scrotum.[3][1]

EraTechniqueLimitation
1993 (Hage bifid)Simple V-Y advancement of labial skinBifid scrotum remains too posterior; n = 50: implant expulsion 7%, dislocation 11%[4]
1993 (Sengezer tissue expansion)Expanders placed in labia majora months before phalloplastyExcellent colour / hair match but requires additional surgical stage + expander complications[5]
2009 (Hoebeke V-Y + 90° rotation)Cranially pedicled U-flaps with rotation + fat-pad relocationAnatomically correct anterior position + adequate bulk in a single stage — modern standard[1]

The Hoebeke technique was developed specifically to overcome the posterior positioning of simple V-Y advancement and the staged-surgery requirement of tissue expansion.[1]

Surgical Technique — Step by Step​

Performed with the patient in lithotomy position, typically concurrent with phalloplasty (RFFF or alternative) and often with vaginectomy / colpocleisis.[6][1]

Step 1 — Flap design​

Three tissue components are designed:[6][1]

  • Bilateral cranially (superiorly) pedicled U-shaped labia-majora flaps — primary scrotal tissue.
  • Pedicled horseshoe-shaped pubic flap — superior / anterior scrotal coverage.
  • Clitoral-hood tissue — additional coverage incorporated into the reconstruction.

Step 2 — Flap elevation​

  • U-shaped labia-majora flaps elevated bilaterally, maintaining the superior (cranial) pedicle to preserve blood supply from the external pudendal arterial system.
  • Inner part of labia minora resected (or, in patients undergoing UL, used for the fixed part of the neourethra).[6]

Step 3 — V-Y advancement​

Labia-majora flaps advanced anteriorly using V-Y principle, moving tissue from native posterior position toward the anterior / inferior pubic region.[1]

Step 4 — 90° medial rotation — the key innovation​

Cranially pedicled U-flaps rotated 90° medially to bring the neoscrotum in front of the legs — the distinguishing step from simple V-Y advancement. Repositions the neoscrotum into the anatomically correct male position (anterior to thighs, inferior to neophallus).[6][1]

Step 5 — Fat-pad relocation for bulk​

Pedicled labia-majora fat pads released bilaterally and relocated into the neoscrotum for bulkiness simulating scrotal volume. Critical step — labial skin alone, even after advancement / rotation, does not provide sufficient volume.[6][1]

Step 6 — Horseshoe pubic flap inset​

Pedicled horseshoe-shaped pubic flap + clitoral-hood tissue incorporated into the superior aspect of the neoscrotum → additional skin coverage + natural penoscrotal junction.[6]

Step 7 — Perineal reconstruction​

  • Without UL: urethral meatus and vaginal orifice (if vaginectomy not performed) diverted underneath the scrotum; perineostomy created at the perineal-scrotal transition.[6]
  • With concurrent vaginectomy: vaginal cavity obliterated; perineum closed in layers.

Step 8 — Closure​

Layered closure of all flaps with tension-free approximation. Resulting scars are minimal and hidden within scrotal folds and hair-bearing skin.[4]

Horseshoe Pubic Flap — Component Detail​

The horseshoe pubic flap is one of three tissue components within the Hoebeke composite scrotoplasty (alongside the cranially pedicled labia-majora U-flaps and clitoral-hood tissue). It is not a standalone scrotoplasty technique but is the critical component that provides:[1][6]

  • Superior scrotal skin coverage — cranial / anterior portion of the neoscrotum.
  • Natural penoscrotal junction — transition zone between neophallus base and scrotum apex.
  • Additional tissue volume — supplements labial flaps when labial tissue alone is insufficient.
  • Hair-bearing, pliable skin — mons-pubis tissue closely matches native scrotal-skin texture, colour, and hair pattern.[9]

Vascular anatomy — superficial external pudendal artery (SEPA)​

Axial pattern flap based on the superficial external pudendal artery (SEPA), a femoral-artery branch:[10][11][9]

  • La Falce 2006 cadaver quantitative anatomy — SEPA present in 92% of individuals; mean diameter 1.2–3.8 mm; duplicated in 46%, common-trunk arrangement with other superficial femoral branches in 24%, single vessel in 30%; distance from SEPA origin to the inguinal ligament 0.8–8.5 cm (significant anatomic variability that must be accounted for during flap design).[10]
  • Deep external pudendal artery (mean internal diameter 0.60 mm) provides additional anterior-perineal supply and contributes to the rich anastomotic network.[11]
  • Cadaver injection studies (Spear 1994) demonstrate the mons-pubis flap has a primary vascular territory (directly SEPA-supplied) and a secondary territory (supplied via anastomoses).[9]

Innervation​

Ilioinguinal nerve + genital branch of the genitofemoral nerve.[12] Sensory innervation of random and pedicled flaps from this region is not substantially affected by mobilisation and corresponds to the local dermatome — the horseshoe pubic flap retains tactile sensation after transfer, contributing to overall neoscrotal sensory quality.[1]

Vulvoscrotoplasty with vaginal preservation (Chen / Berli 2021)​

For patients who desire vaginal preservation alongside scrotoplasty (shaft-only phalloplasty without vaginectomy), the horseshoe pubic flap is modified to construct a masculine-appearing scrotum around the preserved vaginal opening — OHSU vulvoscrotoplasty technique, n = 4 reported.[13]

Vascular pitfalls during concurrent phalloplasty​

The SEPA pedicle of the horseshoe pubic flap may be at risk if the groin dissection required for phalloplasty disrupts its origin from the femoral artery. Miller / Chen n = 147: 83% of distal flap necrosis (5/6) occurred ipsilateral to the groin dissection — the phalloplasty pedicle harvest can compromise both the ipsilateral labial flap and the horseshoe pubic flap.[3] Clinical implication: identify and protect the SEPA before groin dissection; consider preoperative duplex / CTA mapping in re-operative cases.

Anatomic variability and counselling​

  • 8% SEPA absence rate — preoperative assessment and intraoperative confirmation are essential.[10]
  • Body habitus — thick mons can produce excessive bulk; very thin patients may have insufficient tissue. Testosterone therapy may alter regional fat distribution.[14]
  • Prior inguinal / groin surgery — may have disrupted SEPA vessels and compromise flap viability.

Key Technical Refinements​

Over the 300+ case Ghent experience:[1]

  • Sensation preservation — the cranial pedicle maintains ilioinguinal and genitofemoral nerve branches supplying the labia majora → erogenous sensitivity in the neoscrotum (a unique advantage over tissue expansion or grafting).[1]
  • Shaping refinements — progressive modifications to flap design improved 3D contour and natural pendulous appearance.
  • Fat-pad mobilisation — later refinement that significantly improved bulkiness without requiring tissue expanders.[6]

Modification for Patients Without Urethral Lengthening (Pigot 2020 / Amsterdam)​

Pigot 2020 published a specific stepwise modification for phalloplasty without UL:[6]

  • Inner labia-minora tissue (normally used for the fixed neourethra) is resected rather than incorporated.
  • Meatus and vaginal orifice diverted underneath the scrotum.
  • Perineostomy at the perineal-scrotal transition.
  • Result: augmented neoscrotum with minimal visible scars + proper neoperineal length.[6]

Hage Bifid V-Y Advancement (1993) — Historical Predecessor​

Hage, Bouman, and Bloem (Free University Hospital, Amsterdam, 1993) published the first widely described scrotoplasty technique for transmasculine patients (n = 50). It established the foundational principle that labia majora are the ideal donor tissue for neoscrotal reconstruction — the principle that remains central to all modern scrotoplasty techniques.[4] Published in the same year as the Sengezer tissue-expansion technique, the two 1993 publications established the two foundational approaches (direct advancement vs tissue expansion) from which all subsequent scrotoplasty evolved.[4][5]

The V-Y advancement principle​

V-Y is a fundamental plastic-surgery technique:[15][16]

  • V-shaped incision adjacent to a defect creates a triangular flap.
  • Triangular flap advanced to close the defect.
  • Donor site closed in a Y-shaped configuration.
  • Flap maintains blood supply through a deep subcutaneous or fascial pedicle — not detached from its base.
  • Net effect: tissue recruitment from area of excess to area of deficiency.
  • Optimal apex angles 20°–60° — angles < 20° produce excessively long flaps; > 60° result in closure distances at the apex that exceed the original defect width.[15][17]

The V-Y principle allows tissue advancement without tissue expansion — the key Hage advantage over the contemporaneous Sengezer approach.[4][5]

Hage technique — step by step​

Performed in lithotomy position, typically with lengthening of the pars fixa of the urethra:[4]

  1. Incision design — bilateral V-shaped incisions on labial skin (labia majora), apex of each V directed posteriorly/inferiorly, base oriented anteriorly.
  2. Flap elevation — labial skin flaps elevated subcutaneously, deep pedicle preserved for external-pudendal blood supply.
  3. V-Y advancement — each flap advanced anteriorly toward midline, moving labial tissue from posterior native position toward more anterior/inferior location closer to the neophallus base.
  4. Bifid scrotum formation — two advanced flaps sutured to create a bifid scrotum with visible midline raphe / division and two distinct compartments for subsequent testicular-prosthesis placement.
  5. Immediate testicular-prosthesis implantation — prostheses placed into the two compartments at the same operative session (a key difference from modern practice, which favours delayed implantation).[4][2]
  6. Closure — layered closure with small hidden scars in scrotal folds and hair-bearing skin.

Original Hage outcomes (n = 50)​

OutcomeRateNotes
Implant expulsion7%Prosthesis extruded through neoscrotal skin
Implant dislocation11%Prosthesis migrated from intended position
Combined implant-related complications18%Acceptable for the era; superseded by later techniques
Major complicationsFewTechnique described as having "few major drawbacks"
ScarringMinimalHidden in scrotal folds and hair
Tissue expansion requiredNoneDeemed unnecessary with this technique

Limitations driving the Hage → Hoebeke evolution​

The five limitations of the Hage technique that drove the development of the Hoebeke approach:[1][2]

  1. Posterior scrotal positioning — V-Y advancement alone (without rotational component) leaves the neoscrotum between the legs rather than anterior to the thighs. Selvaggi/Hoebeke specifically identified this as the primary problem their 90° medial rotation was designed to solve.[1]
  2. Bifid appearance — can appear unnatural when the two halves don't fuse into a unified pendulous contour.
  3. Insufficient tissue volume — labial skin alone, even after advancement, may not provide enough bulk to simulate testes-containing scrotum; Hage technique lacks fat-pad relocation or horseshoe pubic flap.
  4. Immediate implant placement — associated with higher complication rates vs modern delayed implantation (Amsterdam long-term n = 206: overall explantation 20.8% across all techniques vs 11.5% with modern Hoebeke + delayed implantation).[2]
  5. No rotational component — fundamental biomechanical limitation; cannot reliably reposition the neoscrotum to anatomically correct anterior position.[1]

Evolution to modern Hoebeke technique​

The Ghent team began performing scrotal reconstructions in November 1993 (same year as the Hage publication) and over 300+ cases progressively modified the Hage V-Y advancement by adding:[1][2]

  1. 90° medial rotation of the cranially pedicled labial flaps → solved the posterior-positioning problem.
  2. Horseshoe pubic flap → superior coverage + natural penoscrotal junction.
  3. Pedicled fat-pad relocation → improved bulkiness without tissue expansion.
  4. Delayed implant placement → reduced implant-related complications.
  5. Sensation-preserving refinements → maintained erogenous sensitivity via the cranial pedicle.

Outcome progression: Hage 1993 18% combined implant-related complications → Hoebeke 2019 (Pigot subset n = 52) 11.5% explantation.[4][2]

Current role​

The Hage bifid V-Y advancement is no longer the standard of care — superseded by the Hoebeke technique. Historical importance remains substantial: it established the fundamental principles (labia majora as donor tissue, V-Y advancement for tissue recruitment, avoidance of tissue expansion) upon which all modern scrotoplasty is built.[4] The V-Y advancement principle is itself preserved as a core component of the Hoebeke technique — the Hoebeke approach is essentially a Hage V-Y advancement + 90° medial rotation + horseshoe pubic flap + fat-pad relocation. The Hage technique may retain a role in resource-limited settings where surgical expertise in more complex rotational techniques is unavailable, given its simplicity and reproducibility.[4]

Sengezer Tissue-Expansion Scrotoplasty (1993) — Historical Predecessor​

Sengezer and Sadove (1993) published a two-stage tissue-expansion technique in which expanders are inserted into the labia majora several months before phalloplasty to pre-expand the labial tissue, creating sufficient volume and skin surface area for a natural-appearing neoscrotum.[5] Published in the same year as the Hage bifid V-Y advancement, the two 1993 publications established the two foundational paradigms for scrotoplasty:

  • Hage approach — direct V-Y tissue advancement relying on native labial volume.
  • Sengezer approach — pre-expansion of the labia majora with tissue expanders, biologically growing additional tissue before definitive reconstruction.

The technique drew on the broader tissue-expansion revolution in plastic surgery popularised by Radovan 1984, who demonstrated that intermittent inflation of subcutaneous silicone expanders could double the surface area of adjacent skin while preserving colour, texture, thickness, and sensation with minimal scarring.[21]

Original series (n = 3)​

The total published Sengezer experience is just 3 transmasculine patients.[5] Key findings:

  • Tissue expanders inserted into the labia majora several months before free-flap phalloplasty.
  • 2 patients — expanders removed at phalloplasty and testicular implants placed into the pre-formed pockets.
  • 1 patient — expanders left in place as permanent prostheses (functioning as both expansion device and testicular prosthesis).
  • "Excellent aesthetic results" — natural colour match, hair pattern, skin texture.
  • Anatomical position "properly located in relation to surrounding anatomical structures" — a significant advantage over the contemporaneous Hage technique (which Selvaggi / Hoebeke later criticised for posterior positioning).[5][1]

Biology — mechanotransduction-driven skin growth​

Tissue expansion is not merely stretching — it produces true biological growth of new skin via mechanotransduction:[22][23][24]

  • Mechanoreceptors on keratinocytes and fibroblasts detect sustained overstretch.
  • Protein kinase C (PKC) activated in an isoform-specific pattern — Takei 1998 key mechanosignalling pathway.[22]
  • Growth-factor upregulation → cell proliferation; cytoskeletal reorganisation; collagen synthesis.
  • Net result: net gain in epidermal and dermal tissue, not just elastic stretch.

Janes 2020 porcine isogeometric-analysis temporal dynamics:[23]

TimepointBasal-keratinocyte mitotic index
1 h post-stretch4% (p = 0.022)
Day 3 (peak)26% (p < 0.001)

Cell proliferation showed dose-response to stretch magnitude — larger individual fills produce greater growth stimuli than smaller, more frequent fills, with clinical implications for expansion protocols.

Tissue-biomechanics changes:[23][25]

  • Acute elastic stretch ~25% (chronic ~10%).
  • Acute thickness change −28% (chronic −12%).
  • Chronic fractional weight gain 3.3× (dry weight) — substantial new tissue generation.
  • Longer expansion protocols produce more growth than shorter protocols at the same total volume.

Sengezer technique — step by step​

Stage 1 (months before phalloplasty):[5]

  1. Small incision in each labium majus.
  2. Subcutaneous pocket dissected within each labium.
  3. Silicone tissue expander (integrated or remote fill port) inserted.
  4. Layered closure.
  5. Serial expansion — weekly or biweekly saline fills over 6–12 wk, outpatient.

Stage 2 (at phalloplasty):[5]

  • Option A (2/3 patients) — expanders removed; pre-formed capsule-lined pockets used for testicular implants; phalloplasty performed concurrently.
  • Option B (1/3 patients) — expanders left in situ as permanent prostheses (novel dual-function concept that has not been widely adopted; expanders not designed for permanent implantation).

Advantages​

  1. Anatomically correct scrotal position — labia majora maintained in native anatomic position; correctly positioned scrotum (unlike Hage V-Y which left scrotum too posterior).[5]
  2. Adequate tissue volume — biological growth overcomes the fundamental native-labia-volume limitation.
  3. Natural tissue characteristics — expanded labial tissue retains colour, texture, hair pattern, and sensation.[5][21]
  4. Pre-formed pockets for implants — capsule-lined, ideally sized.
  5. Preserved sensation — nerve fibres elongate with the tissue.[21]
  6. Minimal scarring — donor tissue developed in situ.

Limitations — why the technique was largely abandoned​

1. Additional surgical stage — separate operative procedure months before definitive reconstruction; prolonged timeline; multiple outpatient fill visits; patient discomfort during expansion. Hage explicitly noted tissue expansion is "unnecessary" with the V-Y advancement approach.[4]

2. Tissue-expansion complications. Huang 2011 SR & meta-analysis (n = 5,925, 42 studies): total average complication rate 17.44%.[26]

ComplicationRate
Infection4.58%
Extrusion / exposureVariable (up to 17.7% paediatric)
Combined infection / extrusion (paediatric)23%
Hematoma / seromaVariable
DehiscenceVariable
Device failure (rupture, port malfunction)Rare

Risk factors: lower-extremity location (OR 2.80; 95% CI 1.14–6.86), smoking, radiation.[26] The perineal / genital region wasn't separately analysed but proximity to the perineum raises contamination and infection concerns. George 2026 paediatric series + Wang 2021 antibiotic-prophylaxis provide additional complication-rate context.[27][28]

3. Very small series (n = 3) — extremely limited evidence; no subsequent large series validated the technique.[5]

4. Patient burden during expansion — weeks-to-months of progressively enlarging labial tissue; frequent appointments; visible expansion with social / psychological burden; expander-related complications can delay or prevent definitive reconstruction.

5. Superseded by non-expansion techniques — Hoebeke 2009 demonstrated that adequate scrotal volume and correct anatomic positioning could be achieved without expansion via V-Y advancement + 90° medial rotation + horseshoe pubic flap + fat-pad relocation.[1]

Tissue expansion remains valuable in cisgender scrotal reconstruction​

While abandoned for transmasculine scrotoplasty, tissue expansion remains relevant for cisgender scrotal reconstruction when native tissue is truly deficient (Fournier's gangrene, trauma, tumour excision):[29][30][31]

  • Rapp 2005 — tissue-expanded V-Y scrotoplasty for scrotal-sac reconstruction after extensive skin loss; excellent functional / cosmetic outcomes.[30]
  • Kwon 2008 — rapid intraoperative tissue expansion using 300 cc expanders inflated for only 20 min intraoperatively to expand residual scrotal / medial-thigh skin; enables tension-free closure of ~75% scrotal-skin-loss defects.[29]
  • Atik 2006 — expanded superthin groin flap for total scrotal-tissue loss with 3-week expansion period.[31]

Key insight: modern gender-affirming scrotoplasty avoids expansion because flap-based techniques recruit tissue from multiple sources (labia majora + mons pubis + fat pads) — making the biological-growth step unnecessary. Cisgender reconstruction lacks this multi-source-flap option when native tissue is destroyed.[1]

Current role in gender-affirming surgery​

The Sengezer tissue-expansion technique is no longer used in contemporary gender-affirming scrotoplasty. Entirely superseded by single-stage techniques (Hoebeke, Miller / Chen). Historical contributions:[5][1]

  1. First technique to demonstrate tissue expansion could be applied to the labia majora for scrotal construction.
  2. Established that expanded labial tissue produces a natural-appearing neoscrotum in colour, texture, and hair pattern.
  3. Demonstrated that labial-anatomic-position preservation produces a correctly positioned scrotum — a Hage-V-Y-limitation the Sengezer approach uniquely overcame at the time.
  4. Introduced pre-formed pockets for testicular-implant placement — a concept later refined in staged-implant insertion protocols.

The technique's legacy: adequate tissue volume is essential for natural-appearing neoscrotum — a principle that Hoebeke addresses through fat-pad relocation + horseshoe pubic flap rather than through expansion.[1][6]

Comparison with Alternative Scrotoplasty Techniques​

TechniqueDescriptionAdvantagesDisadvantages
Hoebeke V-Y + rotation (Ghent, canonical)Cranially pedicled U-flaps + V-Y + 90° medial rotation + fat-pad relocationAnatomically correct anterior position; preserved sensation; no tissue expansion; 11.5% explantationTechnically more complex; experienced-surgeon-dependent[1][2]
Hage bifid V-Y (1993)Simple V-Y advancement of labial skinSimple; easy to perform; scars hiddenScrotum too posterior; bifid appearance; 7% expulsion, 11% dislocation[4]
Bilateral rotational advancement (Miller / Chen 2021)Bilateral elevation + rotational advancement posterior → anteriorSingle-stage with phalloplasty; good large-series outcomesn = 147: distal flap necrosis 4.1%; perineoscrotal dehiscence 4.7%; scrotal hematoma 1.4%[3]
Sengezer tissue expansion (1993)Expanders placed in labia majora months before phalloplastyExcellent colour / texture match; natural positionAdditional surgical stage; expander complications[5]

Miller / Chen Bilateral Rotational Advancement (2021) — Largest Dedicated Outcomes Series​

Miller / Chen 2021 (Crane / Chen group; n = 147, Oct 2017–Dec 2019; mean follow-up 12.5 mo) is the largest single-centre series dedicated specifically to scrotoplasty in the gender-affirming literature — larger than the Ghent 300+ patient series (no detailed scrotoplasty-specific complication data) and the Amsterdam 206-patient testicular-implant cohort (focused on implants).[3]

Distinguishing features vs Hoebeke​

  • Bilateral elevation + rotational advancement (vs Hoebeke's cranially-pedicled U-flaps + formal V-Y + 90° rotation + horseshoe pubic flap composite).
  • Creates a unified, pouch-like scrotum (vs Hoebeke composite three-tissue reconstruction or Hage bifid).
  • Integrated perineal reconstruction as a co-step — multilayered closure with inner-thigh skin apposition — not separately described in Hoebeke or Hage publications.
  • No fat-pad relocation, no horseshoe pubic flap — the bulk of the comparative simplicity.

Concurrent procedures​

  • 133 / 147 (90.5%) performed concurrently with single-stage phalloplasty (typically RFFF or pedicled ALT — both require groin dissection).
  • 14 / 147 (9.5%) as secondary scrotoplasty after prior phalloplasty.[18]

Granular complication profile​

ComplicationRaten/NManagement
Distal flap necrosis4.1%6/147Conservative (all 6)
→ Ipsilateral to groin dissection83% of necrosis cases5/6—
Perineoscrotal-junction dehiscence (> 1 cm)4.7%7/147Conservative except 3 with fistulas
Urethrocutaneous fistula at perineoscrotal junction2.0%3/147Surgical fistula repair (all 3)
Scrotal hematoma1.4%2/147Operative evacuation (both)
Perineal hematoma2.0%3/147Operative evacuation (all 3)

Key synthesis from Miller / Chen: "wounds that do not heal may be associated with urethral complications" — non-healing perineoscrotal junctions progressed to urethrocutaneous fistula in 3/7 (43%) of dehiscence cases.[3] Hematomas (3.4% combined) always required operative evacuation — unlike necrosis and dehiscence which were managed conservatively.

The groin-dissection signal — practical implications​

The 83% ipsilateral-to-groin-dissection signal is the single most clinically actionable finding from the Miller / Chen series. The SEPA originates from the femoral artery and courses medially across the groin (see Horseshoe Pubic Flap — Component Detail above for the La Falce 2006 quantitative anatomy). Groin dissection for phalloplasty pedicle anastomosis can directly injure or ligate the SEPA or disrupt the surrounding network.

Four practical implications:[3]

  1. Preoperative flap-design planning — consider groin-dissection laterality; design the ipsilateral flap with wider base or more conservative advancement.
  2. Vascular preservation — identify and preserve the SEPA before groin dissection (where feasible given femoral exposure needs).
  3. Staged-approach consideration — in patients at high risk for vascular compromise (prior groin surgery, obesity, smoking), consider staging scrotoplasty separately from phalloplasty.
  4. Contralateral planning — if possible, position the phalloplasty vascular anastomosis contralateral to the dominant labial flap.

Massie 2017 — bulbospongiosus-flap-from-vaginectomy reduces urethral complications​

A separate Crane / Chen group publication (Massie 2017, n analysis) demonstrated that adding a vascularised bulbospongiosus flap from vaginectomy during phalloplasty with UL is associated with:[19]

  • Decreased urethral stricture — OR 0.25 (p = 0.047).
  • Decreased fistula formation — OR 0.13 (p = 0.004) vs vaginal preservation.

Implication for the Chen / Berli vulvoscrotoplasty-with-vaginal-preservation variant: patients choosing vaginal preservation must be counselled about the markedly higher urethral-complication risk when UL is also performed.

Ascha 2018 ALT-vs-RFFF comparison​

Single-stage phalloplasty outcomes (same group):[20]

  • Pedicled ALT vs RFFF — both require groin dissection; both compatible with concurrent Miller / Chen scrotoplasty.
  • Choice of flap should account for the ipsilateral-flap-necrosis risk identified in the Miller / Chen series.

Limitations of the Miller / Chen approach​

  • No long-term testicular-implant data (mean follow-up only 12.5 mo; implants placed at later stage) — unlike Amsterdam 11.5-yr testicular-implant series.[2]
  • No fat-pad relocation or horseshoe pubic flap — lacks the bulkiness and penoscrotal-junction refinements of the Hoebeke approach.
  • No sensation data — neoscrotal sensation / erogenous sensitivity not reported (a documented Hoebeke advantage).[1]
  • Retrospective design without validated PROMs.

Outcomes — Hoebeke Technique Specifically​

Ghent / Amsterdam series:[1][6]

  • No major complications related to scrotoplasty in the original 300+ patient series.
  • All patients pleased at short- and long-term follow-up with scrotum in its natural anterior position.
  • Neoscrotum closely resembles biological scrotum in bulkiness, size, shape, tactile sensation, and anatomical position.

Testicular-implant outcomes with Hoebeke scrotoplasty (Pigot 2019 Amsterdam, n = 52 Hoebeke subset):[2]

  • Explantation rate 11.5% (6/52) — significantly lower than the overall 20.8% explantation rate across all techniques in the same centre's 206-patient series.
  • Improvement attributed to Hoebeke technique + trend toward smaller / lighter prostheses + delayed implantation.
  • Smoking significant risk factor for postoperative infections and prosthesis explantation on univariate and multivariate analysis.

See the Testicular Implants (Gender-Affirming) page for the full implant-outcomes framework.

Timing Within the Surgical Sequence​

Hoebeke scrotoplasty is typically performed as part of the second surgical stage:[7]

  1. Stage 1 — chest reconstruction; hysterectomy ± BSO.
  2. Stage 2 — vaginectomy + scrotoplasty (Hoebeke technique) + metoidioplasty or phalloplasty + urethroplasty.
  3. Stage 3 (~6 mo later) — testicular implant placement.
  4. Stage 4 (9–12 mo after phalloplasty) — penile prosthesis insertion if phalloplasty performed.

Per ACOG, testicular implants can be placed approximately 6 months after scrotoplasty.[8]

Concurrent Procedures and Vascular Considerations​

When performed concurrently with phalloplasty, the scrotoplasty flap design must account for the groin dissection required for the phalloplasty vascular pedicle. Miller / Chen 2021 (n = 147): 5 of 6 distal flap necrosis cases (83%) occurred ipsilateral to the groin dissection — the phalloplasty pedicle harvest may compromise blood supply to the ipsilateral labial flap.[3] Important consideration when planning Hoebeke concurrently with RFFF phalloplasty, as the vascular anastomosis is typically performed in the groin.

Summary — Why Hoebeke Has Become Standard​

The Hoebeke technique addresses all the key goals of scrotoplasty:[6][1][2]

  1. Anatomically correct position — 90° medial rotation brings neoscrotum anterior to legs.
  2. Adequate volume — fat-pad relocation provides natural bulk without tissue expanders.
  3. Preserved sensation — cranial pedicle maintains innervation → erogenous sensitivity.
  4. Single-stage reconstruction — no prior tissue expansion needed.
  5. Minimal scarring — hidden in scrotal folds / hair-bearing skin.
  6. Low complication rate — no major complications in original series; 11.5% testicular-implant explantation vs 20.8% historical mix.
  7. Compatibility with staged implant placement — neoscrotum designed to accommodate testicular prostheses at later stage.

Evidence Limitations​

  • Selvaggi 2009 / Hoebeke 300+ patient experience is the seminal technique description but is single-centre and retrospective.[1]
  • Pigot 2019 n = 52 Hoebeke subset is the largest specific outcomes anchor; the 11.5% vs 20.8% explantation contrast reflects within-centre technique evolution rather than a controlled comparison.[2]
  • No randomised comparisons between Hoebeke, Hage bifid, Miller bilateral-rotational, and Sengezer tissue-expansion techniques.
  • Long-term outcomes (sensation durability, scrotal-skin remodelling) beyond 10 yr poorly characterised.

References​

1. Selvaggi G, Hoebeke P, Ceulemans P, et al. Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty. Plast Reconstr Surg. 2009;123(6):1710–1718. doi:10.1097/PRS.0b013e3181a659fe

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